HDFC ERGO General Insurance Company Limited 2825205921436200000

2825205921436200000

2825

Dear MR DESH BANDHU SHARMA

NO 117/Q/750-A-1 SHARDA NAGAR NEAR GURUDEV

PALACE NAVEEN NAGAR KANPUR NAGAR

KANPURPINCODE - 208025
KANPUR, UTTAR PRADESH, 208025
Contact No. 99XXXXXXX2

Date :06/12/2023

Thank you for choosing HDFC ERGO as your preferred insurance partner. We welcome you to be a part of our family !
Your Health insurance policy reference no 2825205921436200000 i s confirmed on the basis of the information and declaration given by you.The details of coverage are
mentioned in the enclosed policy schedule of insurance.

As a measure of our customer convenience we have implemented a Lifetime Validity Health Card. For you, this simply means that your Health Card is valid for all subsequent
renewals and as long as your policy is active with us. Hence, you need not replace your health card every year.

We value your relationship with us and assure you our best services at all times and we look forward to serve you.
Now you can view your policy details and health card at your fingertips. Download our Mobile App now and experience convenience today!!"

Proposer details have been updated basis the information present in the KYC documents. If you find any detail which needs to be corrected, request you to create/ modify the
eKYC ID and place a request for endorsement.

Soft copy of the policy is valid for all purposes including claims.

For HDFC ERGO General Insurance Company Ltd.

Arun Sharma
Head - Customer Experience Management

HDFC ERGO General Insurance Company Limited

TAX CERTIFICATE

Dear Desh Bandhu Sharma,

Subject : Certificate for the purpose of deduction under section 80 D of Income Tax (Amendment) Act, 1986

This is to certify that we have received an amount of ` 87,587.00 towards premium for Policy No. 2825205921436200000 issued to DESH BANDHU SHARMA for the
period 06/12/2023 to 05/12/2024.
Note : This is subject to the provisions of Section 80D of income tax (Amendment) Act, 1986 as amended from time to time.
Deduction under Section 80D can be claimed only on payment of the premium. In case where all the installment are not paid, the deduction to be claimed under section 80D will be
restricted to the proportion of the premium actually paid.In case of free look cancellation or otherwise, the benefit under this section would be nullified or prorated, as applicable.
For HDFC ERGO General Insurance Company Ltd.

Date : 04/12/2023
Policy Issuing Office: Mumbai
Duly Constituted Attorney

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN:HDFHLIP24079V072324. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited 2825205921436200000
Policy Schedule
my:health Suraksha Policy
( GOLD SMART )

2825205921436200000

Policy No. : 2825 2059 2143 6200 000 Issuance Date : 04/12/2023
Period of Insurance : From 06/12/2023 00:01 hrs To 05/12/2024 Midnight
Invoice No. : 205921436200000 Premium Frequency : Single
Proposer Name : Mr Desh Bandhu Sharma Policy Type : Family
MR DESH BANDHU SHARMA HSN Code : 997133 PAN No. : AFPPS4195A
NO 117/Q/750-A-1 SHARDA NAGAR NEAR GURUDEV Customer Id : 100768664127
PALACE NAVEEN NAGAR KANPUR NAGAR
KANPURPINCODE - 208025 KANPUR, UTTAR PRADESH-
208025
Contact No : 99XXXXXXX2 EIA No. : Not provided
Payment Details : 202312040044936
Email ID : bdxxxxxxxx52@gxxxx.com
my:health Suraksha - Insured Person’s Details & Sum Insured
Insured's Relation with Gender DOB Nominee Name Nominee 1st Policy Basic Sum Tier CB Amount Unlimited Pre Existing
Name policy holder Relationship Inception Insured (`) (`) Restore Add Disease
on (Y/N)
Desh Bandhu Self Male 10/02/1954 Manju Lata SPOUSE 06/12/2021 1500000 Tier 2 0
Sharma Sharma
Manju Lata Wife Female 15/05/1955 Desh Bandhu SPOUSE 06/12/2021
Sharma Sharma
Unlimited Restore UIN No: HDFHLIA22188V012122
Schedule of Coverage
Section Covers Details/ Applicability of Sum Insured Limit
Base Covers
A Hospitalization Cover up to Basic Sum Insured including cumulative Bonus Basic Sum Insured and CB
Medical Expenses Basic Sum Insured and CB
1B Mental Healthcare Basic Sum Insured and CB
2 Home Healthcare Basic Sum Insured and CB
3 Domiciliary Hospitalization Basic Sum Insured and CB
4 Pre-Hospitalization 60 Days
5 Post-Hospitalization 180 Days
6 Day Care Procedures Basic Sum Insured and CB
7 Road Ambulance cover Sub limited within the Basic Sum Insured including SI 1 to 5 L -2,000
Cumulative Bonus SI 6 to 50 L -3,500
SI Above 50 L -15,000
8 Organ Donor Expenses upto Basic Sum Insured including cumulative Bonus Basic Sum Insured and CB
9 Alternative Treatment upto Basic Sum Insured including cumulative Bonus Basic Sum Insured and CB
C1 Preventive Health Check Up -Booster over and above the Basic Sum Insured Covered Up to 1% of Basic Sum Insured max
upto Rs 5,000, on every renewal
C4 Air Ambulance Cover over and above the Basic Sum Insured 200000
C5 Recovery Benefit over and above the Basic Sum Insured 15000
C6 Sum Insured Rebound over and above the Basic Sum Insured Upto 100% of Basic Sum Insured
C11 Waiting Period Modification Option Reduction in the standard waiting period as opted for 3 Years
Renewal Benefits
1 Cumulative Bonus Applicable
2 my:health Active Applicable
Waiting Periods
Sec E 1 i - General waiting period - 30 days from Policy inception date
Section A Hospitalization Cover Sec E 1 ii - Listed illness & procedures - 24 Months
Sec E 1 iii - Preexisting conditions - 36 Months
Premium Details (`)
Basic Premium 74225.68
Medical U/W Loading + 0
Total Premium (Insured) excluding Tax 74226.00
GST 18% : Central Tax 9% ( `6680.5 ) + State Tax 9% ( `6680.5) 13361.00
Total Premium (Including Taxes) 87587.00
Special Conditions : For Rs 1500000 Sum Insured - Sec E 1 i , Sec E 1 ii and Sec E 1 iii to be considered as per the policy inception date as 06/12/2021 Insured Mr. Desh Bandhu Sharma.,For Rs
1500000 Sum Insured - Sec E 1 i , Sec E 1 ii and Sec E 1 iii to be considered as per the policy inception date as 06/12/2021 Insured Mrs. Manju Lata Sharma.
For declared and accepted pre-exiting medical conditions, waiting period (s) shall apply per policy terms and conditions from 1st policy inception date of the
policy, fresh waiting period (s) shall apply on enhanced sum insured.

For Claim/Policy related queries call us at +91- 22 6234 6234/+91- 120 6234 6234 or Visit Help Section on www.hdfcergo.com for policy copy/tax certificate/make changes/register & track claim.
The policy is valid subject to payment received by us. If the premium is not realised the policy shall be void from inception.Consolidated stamp duty for this Insurance Policy is paid by Demand Draft,
vide Receipt/Challan noLOA/CSD/547/2022/5450/22 dated 22/12/2022 as prescribed in Government of Maharashtra Order No. Mudrank-2017/CR.97/M-1, dated the 09th January 2018;. GST
Registration No: 09AABCL5045N1Z6 .GST for this invoice is not payable under reverse charge basis. I/ We hereby declare that though our aggregate turnover in any preceding financial year from
2017-18 onwards is more than the aggregate turnover notified under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule

Branch :2nd floor, virendra smriti complex civil lines kanpur nagar

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN:HDFHLIP24079V072324. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
 HDFC ERGO General Insurance Company Limited 2825205921436200000

Policy Schedule

Agent Name : DEEPSHIKHA TOMAR CHAUHAN For HDFC ERGO General Insurance Company Ltd.
Agent Code : 201655707427 Tel No. : 91-9838182627

Duly Constituted Attorney

"For detailed policy terms and conditions please visit our website https://www.hdfcergo.com/download/policy-wordings."

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN:HDFHLIP24079V072324. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
 PORTABILITY FORM

Kindly provide complete and correct information. Incomplete, incorrect or partially correct information will lead to cancellation of policy.
How many members woluld you like to cover : 2

POLICY HOLDER / INSURED MEMBERS DETAILS

Member -1
Name of Insured DESH BANDHU SHARMA
Date of Birth 10/02/1954
Address
Gender M
No of Years of continuous coverage ?
Details of Existing Insurance & Insurer
Year 1
Name of insurer STARHEALTH
Name of Product
Policy Number 11230217049701
Sum Insured 1500000
Cumulative Bonus 0
Add-ons/Ridders Taken
Start Date of Policy 06/12/2022
End Date of Policy 05/12/2023
Any Claims Logged NO
Pre Existing Diseases 0

Whether cumulative bonus to be converted to an enhanced sum insured 0

Please state your reason for Portability ?

Member -2
Name of Insured MANJU LATA SHARMA
Date of Birth 15/05/1955
Address
Gender F
No of Years of continuous coverage ?
Details of Existing Insurance & Insurer
Year 2
Name of insurer STARHEALTH
Name of Product
Policy Number 11230217049701
Sum Insured 1500000
Cumulative Bonus 0
Add-ons/Ridders Taken
Start Date of Policy 06/12/2022
End Date of Policy 05/12/2023
Any Claims Logged NO
Pre Existing Diseases 0

Whether cumulative bonus to be converted to an enhanced sum insured 0

Please state your reason for Portability ?

Declaration
I am aware that the waiting period for the following disease(s) /treatments is ...days /years more than the previous policy terms .I here agree to observe the
additional waiting period for the following disease(s)/ treatments(s)
I AGREE

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN:HDFHLIP24079V072324. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited 2825205921436200000

HDFC ERGO General Insurance Company Limited 2

Policy No.:2825205921436200000 This card is for identification purpose only.
Valid From: 06/12/2023 Renewal Date: 5 December
Card has to be presented to the Network Service Provider at the time of admission/ availing
cashless hospitalization o r any other services. Insurance claim will be processed in accordance
Insured Name Member ID Date Of Birth Gender
with the policy term & conditions. Card does not guarantee cashless hospitalization or any other
service. For more details and updated list of Network Service Provider please refer our website or
DESH BANDHU SHARMA 2023310034047895 10/02/1954 Male call our call centre. This card is valid till the time policy is active.

MANJU LATA SHARMA 2023310034047896 15/05/1955 Female

Customer Service No : 022 - 6234 6234 / 0120 - 6234 6234

Email : healthclaims@hdfcergo.com
Processing Centre : HDFC ERGO General Insurance Company Ltd. 5th floor,
Tower 1, Steller IT Park, C-25, Sector-62,Noida-201301.
Website : www.hdfcergo.com

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN:HDFHLIP24079V072324. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com